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Above the Fold

Is North Carolina Medicaid the Healthcare Industry’s Solyndra?

Feb 21, 2012• 31

By Al Lewis

North Carolina Medicaid recently reported, for the third time, using a third consulting firm, the achievement of massive savings through its patient-centered medical home (PCMH) program, now called Community Care of North Carolina (CCNC). Among other things, CCNC pays the physicians more money in order to encourage and compensate behaviors and processes, including enhanced access to care and case management, to hopefully reduce the need for emergency and inpatient services. (A brief summary of this and past consulting reports appear in the current issue of Modern Health Care. http://www.modernhealthcare.com/article/20120218/MAGAZINE/302189938/1140)

However, the third time is not a charm. Notwithstanding these consultants’ reports — which paradoxically support my contrary conclusions by choosing to ignore the overwhelming data contradicting their own claims – the program is a total failure as far as reductions in cost and inpatient utilization are concerned.

Fact #1: According to the Medicaid and CHIP Payment and Access Commission (MACPAC) report to Congress http://www.macpac.gov/reports, North Carolina is by a significant margin the highest-cost state per capita in its region for adult and for child Medicaid spending. These are the two categories in which the PCMH has been in place the longest. In the “aged” category, in which PCMH had barely been started when the MACPAC data was compiled (and would not affect medical costs noticeably because the state is a “secondary payer” following Medicare, and most Medicaid “aged” spending is custodial anyway), North Carolina is the lowest cost state in the region.
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A New Grassroots Movement By Doctors

Feb 21, 2012• 6

By Ron Gutman

There’s a new movement in healthcare – and it’s growing from a surprising place. Instead of emerging from government or industry, it’s budding from the grassroots –from everyday physicians. The movement is democratizing health information and giving birth to a new landscape: Interactive Health.

Interactive Health is transitioning clinical care from real-world, costly encounters to virtual, inexpensive, cloud-based care. And the view from the cloud is better. This transformation is starting with the most fundamental interaction in healthcare: patient question, physician answer.

In late April of 2011, HealthTap decided to help facilitate this movement by bringing together physicians to engage online and create a roadmap for “care in the cloud.” Nine months later, the growth of physician engagement on HealthTap and beyond proves that Interactive Health is here to stay.

Politics in the Exam Room

Feb 20, 2012• 1

By David M Sack MD

An ancient maxim of dinner party etiquette, which I believe has been proffered from more than one source, is “never discuss politics, religion or sex in polite company”. In some ways, for me as a physician, entering the exam room with a patient seems to require some similar degree of discretion. But the consequences of straying outside the bounds of polite discussion in the doctor’s exam room are quite different from any awkwardness that might ensue after a social misadventure.

Dr. Henry Lee, the well-known Connecticut State forensic medicine expert likes to relate a tale of his own introduction to dinner party etiquette, which I will try to relay somewhat faithfully. His English was poor when he arrived in the U.S. and, invited to a party in which guests were seated in the traditional “boy-girl-boy-girl” arrangement, he knew he would be pressed to make conversation with the women on each side of him. A friend reassured him, “You’ll have no problem if you can just get the woman talking about herself and then all you have to do is listen politely. Simply ask ‘Are you married?’ and then ask “Do you have any children?’. This should get things going just fine.” Armed with this strategem, Dr. Lee was seated and turned to an attractive young woman on his left and asked if she was married. She replied “No”. So of course, he went on to the next question, “Do you have any children?”. He was surprised when she reacted with a look of indignation and quickly turned her attention to the guest on her other side. Puzzled at her reaction, he surmised that he must have gotten the sequence out of order. Trying out the other way around, he turned to an older woman on his right and asked confidently if she had any children. “Three!”, she replied happily. Delighted with his progress, he then inquired if she was married. Dr. Lee says he spent the dinner conversing with his soup and salad.

I have also had exam room encounters come to grief because of sex, politics and religion, but nothing has caused me more regret than politics. I will explain.

Forecast and Ramifications of Payers in the HIE Market

Feb 20, 2012

By Naveen Rao

The numerous changes in the healthcare sector are forcing stakeholders to develop new business models to prosper, to survive. Among health insurers, this means one thing: diversification. Health reform was the nail in the coffin of yesterday’s business model, a model that had no restrictions on margins, a model where payers sold to businesses, not individuals. Tomorrow’s strategy for payers is still a work in process but one thing is clear, its foundational elements will be consumers, technology and data. The emerging world of big data in healthcare is providing payers with new potential ways to make profits. Beyond the promise of efficiencies, some payers are beginning to look closely at harnessing the flow of clinical, claims and administrative data to allow for the creation of stand-alone business opportunities. Specifically, information exchange will grow in importance in 2012 and beyond as value-based payment models rely to increasing extents on the availability of diverse types of data at the point of care.

So why have payers been so cautious to jump on board and fund HIE’s?

The answer is multi-faceted. First and foremost is simply the issue that many a provider is uncomfortable with a payer having direct access to clinical data and is thus unwilling to share such data with an HIE that has payer involvement. Second is the business uncertainty at this early stage of HIE maturity. The HIE market remains very dynamic and there is a lot of uncertainty as to where this market will eventually lead. Before putting some parameters around the direction of payer-involvement in the HIE market, it bears a quick run-through of what the different models of payer involvement look like today.

Vegas, Baby, Vegas

Feb 20, 2012

It seems that I just got back from Vegas and CES although I had 3 weeks in India & Hong Kong in between. But in a few minutes I’ll be off there again as this time HIMSS brings its modest 40,000 attendees to Vegas. (When I say modest, CES had 200K!) THCB and Health 2.0 News will be there in force with me, Laura Montini & Jennifer Lee looking dangerous with our flip cams, while Health 2.0ers Marco Smit, JL Neptune & Pat Ryan will be working with AT&T, ONC, Novartis and other clients. And to those of you following on Twitter, the red satin jacket was the winner in the poll for what I’ll be wearing as fashion judge at HISTalkpalooza (and afterwards Regina Holliday will paint it!). So expect lots of video interviews on THCB and Health 2.0 News in the next days and weeks, and wish us luck as we descend into miles of walking all fueled by too much alcohol and too little sleep!

Dial Back The Hype

Feb 19, 2012• 7

By DAVID WHELAN

I like health Web sites and tech start-ups. I think the democratization of medical information is a beautiful thing. It’s a cliche that you can find out more about a hotel than a doctor with a few Google searches. I love how that’s starting to change. I also think that electronic medical records will improve health care over the long haul.

But I am also cynical about the idea that technology is some sort of panacea all that ails the sector. I read Michael Lewis’s book The New New Thing when it came out in 1999. There’s a great anecdote in it about Netscape founder Jim Clark. He was looking for another big challenge and decided–this was 1996–that all that was missing from health care was good software. So he started Healtheon. To Clark it was just a matter of writing some really good code and all the inefficiencies and paperwork that bedeviled the industry would go away. His business plan was a flow chart showing how software cuts out paperwork. It was simple.

Flash forward and Healtheon is buried somewhere deep inside WebMD. There’s still a lot of waste and paperwork that hasn’t gone away.

Since Clark there has been a parade of other ambitious health-tech entrepreneurs. Do you remember the search engine Wondir? Or the comparison-shopping site Vimo? Or Carol.com? How about Steve Case‘s modestly named Revolution Health? What about Subimo?

If HHS Delays ICD-10 Long Enough, Could the U.S. Adopt ICD-11 Instead?

Feb 19, 2012• 1

By Tom Sullivan

The case for leapfrogging ICD-10 and holding out for ICD-11 just got a lot more curious. And though it’s not here yet, when ICD-11 is ready, it will be something ICD-10 cannot: A 21st Century classification system.

Now that HHS Secretary Kathleen Sebelius has thrown her department’s hat in the ring, saying late Wednesday that HHS intends to delay ICD-10, the most pertinent question is how long will HHS push back compliance?

“My opinion is that CMS won’t be able to announce three months or six months of delay for ICD-10,” says Mike Arrigo, CEO of consultancy No World Borders (pictured at left). “They will need to announce a delay from October 1, 2013 to at least October 1, 2014 because of CMS fiscal planning calendars.”

Others in the industry are suggesting that even one year is not enough to lighten the burden on physicians, providers and payers enough to make the transition smoother.

“I have a gut feeling they’ll go for two years, who knows?” speculates Steve Sisko, an analyst and technology consultant focused on payers and ICD-10. “Maybe January 2015?”

No more mixed signals

There it is on the Department of Health and Human Services Web site, a crystal-clear headline atop a brief explanatory statement: HHS announces intent to delay ICD-10 compliance date.

“We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead,” Sebelius said in the statement. “We are committing to work through the rulemaking process, with the provider community, to reexamine the pace at which HHS and the nation implement these important improvements to our healthcare system.”

Anytime We Consider Anything Less than Everything, We Are Missing Something.

Feb 18, 2012• 1

By J. Paul Neeley

When we design today, we isolate problems and then create solutions for them, and we then celebrate those solutions. But in reality we have no idea exactly what we’ve done, because in focusing on any particular problem we have really just ignored everything else. We have failed to engage with the complex realities of our interconnected world, and in our attempts at solutions have only created more problems, the cumulative effect of which can be devastating.

When we really understanding the implications of this idea, we soon realize that in our design of anything, we must consider everything. There is no part of the entire system that isn’t affected by every other part of the entire system. This idea became very clear to me while working in healthcare. You can’t solve for a particular condition in isolation… it interacts in complex ways with the system of rest of the body. When you consider the entire body, and you soon realize that you can’t solve for the health of the individual in isolation… it interacts in complex ways with the social systems, culture, the environment, and on and on. Changes to any part of that system can have dramatic, complex, unforeseen, unintended, and often unknown consequences in other parts of the system.

The Trouble with Treating Patients as Consumers

Feb 17, 2012• 7

By Augusta Meill and Gianna Ericson

To be a patient today is to be treated as a consumer. But treating patients as typical proactive, in control, well-informed consumers can backfire. Asked to take on increasingly complex decisions and digest ever-larger amounts of information, patients find themselves placed — often by design — in the driver’s seat. High-deductible insurance plans aspire to make the cost implications of care more transparent and implicitly shift decision-making to members. The “empowered patient” movement encourages patients to become hyper-informed and to take control over their care. But providing greater information, access and autonomy — so often successful in consumer settings — does not necessarily drive better care or experience. Consider these cases:

An unexplained black-out sent a 61-year-old Boston woman to the emergency room and set off a flurry of visits to specialists to uncover the cause. Each doctor needed records of the diagnostics from previous visits. Hospital policy, however, required that patient data be released only to the patient, meaning she had to return to the hospital prior to any new specialist visit. Requiring her to control the information flow burdened her in the midst of a medical crisis.
After years of struggling with her weight, a New York mother underwent bariatric surgery. She was inundated with information from her medical team about how she would need to change her behavior. Guidelines around when, how, and what to eat or not eat — the rules were overwhelming and constraining. Before long her weight had jumped again. For this woman, an excess of information (along with an assumption that she was prepared to absorb it) was part of the problem, not the solution.

Can the Press Save DSM 5 from Itself?

Feb 17, 2012• 2

By Allen Frances, MD

DSM 5 has suddenly become a star press attraction. In just the last three weeks, more than 100 news stories featuring DSM 5 appeared in major media outlets located in more than a dozen countries. (For a representative sample see Suzy Chapman’s post on Dx Revision Watch.) The explosion of interest started with a flurry when The New York Times published two long DSM 5 articles and three DSM-5-related op-ed pieces, all within a few days. An unrelated press conference in London then generated a widely distributed Reuters story and also many independent pieces. Several other reporters had also been working on their own DSM 5 stories that just happened to arrive at the same time.

The intense press scrutiny of DSM 5 is really just beginning. I know of at least 10 additional reporters who are preparing their work now for publication in the near future. And many of the journalists whose articles appeared during these last few weeks intend to stay on this story for the duration — at least until DSM 5 is published, and probably beyond. They understand that DSM 5 is a document of great individual and societal consequence — and that its impact and risks need a thorough public airing.

The press coverage has been almost uniformly and devastatingly negative. The two most common themes are 1) DSM 5 will radically expand the boundaries of psychiatry, medicalising normality and leading to unneeded and harmful treatment; and 2) DSM 5 decisions are being made arbitrarily, based on narrow input and lacking sufficient scientific support. The DSM 5 proposals that have elicited the most concern are changes in the definition of autism and the expansion of major depressive disorder to capture much of normal grief.

The articles sometimes contain small inaccuracies and sometimes emphasize peripheral issues. And the most dangerous DSM 5 proposals get far too little mention. I will discuss in later blogs how DSM 5 will worsen the over-diagnosis of attention-deficit disorder and the over-prescription of antipsychotic mediation. But the press has gotten the main points just right and somehow manages to see the risks of DSM 5 much more clearly than do the people working on it.